Radiosurgery for Cavernous Malformations and Other Vascular Diseases

First author

Patients

FU length

Lesion location

Clinical presentation

Annual bleeding risk

Comment

Robinson [7] (1991)

66 patients

26 months

Supratentorial: 55 patients

Seizures: 34 patients

0.7 % per lesion

– HRG common in female and in infratentorial lesions

Deep: 4 patients

Focal deficit: 30 patients

Cerebellar: 9 patients

HRG: 6 patients

Brainstem: 8 patients

Incidental: 9 patients

Zabramski [4] (1994)

31 patients

2.2 years

Supratentorial: 92 %

Symptomatic: 61 %

HRG + symptom: 6 %

– Developed new cavernoma: 29 %

Multi: 84 %

Infratentorial: 8 %

Incidental: 39 %

HRG overall: 13 %

Aiba [22] (1995)

110 patients

4.71 years

Supratentorial: 65 %

HRG: 62 patients

Re-HRG: 22.9 % per lesion

– Younger and female patients had higher HRG risk

Deep: 11 %

Seizures: 25 patients

Brainstem: 18 %

Incidental: 23 patients

Kondziolka [23] (1995)

122 patients

34 months

BG/thalamus: 17 %

HRG = 1: 41 %

Total: 2.6 %

– No influence on location, sex, and number on HRG risk

Multi: 20 %

Brainstem: 35 %

HRG > 1: 9 %

No HRG: 0.6 %

Seizures: 23 %

Previous HRG: 4.5 %

Porter [2] (1997)

173 patients

46 months

Superficial: 109 patients

HRG: 25.4 %

4.2 % annual rate

– Significantly greater

Multi: 17.9 %

Deep: 64 patients

Seizure: 35.8 %

10.6 % deep location

Bleed rate for deep

Neurological deficit: 20.2 %

~37 % recovered from

Incidental: 12.1 %

new deficits

Labauge [11] (2000)

40 patients

3.2 years

Supratentorial: 176

HRG: 19 patients

11 % per patient

– 1/3 bleeds, symptomatic

Multi: 93 %

Cerebellar: 30

Seizures: 12 patients

2.5 % per lesion

– 27.5 % of patients develop new lesions

Brainstem: 26

Focal signs: 4 patients

Kupersmith [24] (2011)

37 patients

4.9 years

– 12 midbrain

HRG: 73 %

2.5 % per patient

– Young patient with lesion of >10 mm had higher risk of HRG

– 18 pons

Mass effect only: 22 %

5.1 % rebleeding risk

– 7 medulla

Asymptomatic: 5 %

Al-Holou [10] (2012)

92 patients

3.5 years

Supratentorial: 75 patients

Acute symptoms: 17 patients

HRG: 1.6 %/year

– Brainstem location

Multi: 30 %

Infratentorial: 1 patient

Chronic symptoms: 5 patients

Re-HRG: 8 %/year

and age increased

Incidental: 34

0.2 % if incidental

bleed rate

Salmon [25] (2012)

139 patients

5 years

Lobar: 67 %

Incidental: 47 %

HRG: 2.4 %/year

– Risk declines over

Multi: 17 %

Brainstem: 14 %

Seizure: 25 %

Re-HRG: 29.5 %/year

5 years and is higher

Cerebellum: 13 %

HRG: 12 %

HRG year 1: 19.8 %

for women

Deep structures: 6 %

Neurological deficit: 15 %

HRG year 5: 5 %

HRG hemorrhage, ARE adverse radiation effect, BG basal ganglia

In older patients or patients with low-risk lesions which are difficult to reach surgically, observation with periodic imaging may be appropriate. When patients present with recurrent hemorrhage, progressive neurological deterioration, or intractable epilepsy, then treatment in the form of surgery or radiosurgery should be considered. The management options for a patient with a cavernous malformation must be based on age, symptoms, hemorrhage risk, and location, especially as it relates to surgical accessibility. Resection clearly provides immediate advantages for accessible lesions and complete resection is achieved in 91 % (62 % bleed rate in partially resected lesions) [26]. However, surgery on average has a 45 % postoperative and 15 % long-term morbidity [26]. These results can be much higher when resection of deep-seated lesions is conducted (Table 50.2) [27–33]. For younger patients with more accessible lesions, the removal of lesions may help control epilepsy, improve neurological deficits, and prevent any subsequent hemorrhage. Radiosurgery is a minimally invasive option for patients presenting with recurrent hemorrhages from deep-seated cavernous malformations.

Table 50.2

Summary of reports on resection of deep-seated cavernous malformations

First author	Patients	Location	Presentation	Immediate postoperative outcome	Long-term outcome
Steinberg [27] (2000)	56 patients	Brainstem: 42	HRG: Average of 2.1	16 % improved	43 % improved
		Thalamus: 5		55 % stable	52 % stable
		Basal ganglia: 10		29 % worse	5 % worse
				No death	4 patients had re-HRG
Mathiesen [28] (2003)	68 patients	Basal ganglia: 11	Varied with location	25/29 complete resection	Re-HRG: 4 partial resections
		Thalamus: 12	HRG 1 or 2: 68 patients	69 % neuro-decline	20 patients improved
		Mesencephalon: 5		Only 2 (5 %) permanent	(10 patients intact)
		Pons: 31			4 stable, 5 worse
		Medulla: 5			1 died of rebleed
Wang [29] (2003)	137 patients	Midbrain: 29	HRG = 1: 45 patients	131/137 total resection	Re-HRG: 3 partial resections
		Pons: 85	HRG > 1: 58 patients	72.3 % stable or improved	Death: 1
		Medulla: 19	HRG 3 or more: 34 patients	27.7 % new deficits	7.8 % living dependently
		Cerebellar peduncle: 8	60 % annual rebleeding
Ferroli [30] (2005)	52 patients	Medulla: 7	HRG = 1: 32 patients	4 repeat surgeries	19 % permanent deficits
		Pontomedullary: 3	HRG > 1: 18 patients	29 patients stable
		Pons: 31	No HRG: 2 patients	23 patients worse
		Pontomesencephalic: 3	HRG: 3.8 % annual risk	1 death
		Midbrain: 6	Re-HRG: 34.7 % annual
Hauck [31] (2009)	44 patients	Pons: 25	HRG = 1: 20 patients	Improved: 30 %	Residual: 1
		Midbrain: 11	HRG > 1: 23 patients	Stable: 59 %	Re-HRG: 2 patients
		Medulla: 8		Worse: 11 %	Revisions: 8 patients
Abla [32] (2011)	260 patients	Pons: 112	HRG: 252 patients	New deficits: 53 %	Death: 3
		Medulla: 29	New deficits: 7 patients	Residual lesion: 29	New deficit: 36 %
		Midbrain: 49		Re-HRG: 7.7	Improved: 45 %
		Pontomedullary: 40		Died: 2	Re-HRG: 2.0 %
		Pontomesencephalic: 31
Pandley [33] (2012)	176 patients	Pons: 94	HRG = 1: 70 patients	Second operation: 17 patients	Death: 3
	20 pediatric	Midbrain: 28	HRG > 1: 102 patients	New deficit: 31.3 %	Improved: 61.8 %
		Medulla: 14	Seizure: 4 patients	Improved: 19.9	Stable: 25.9 %
		BG/thalamus: 43			Re-HRG: 5 patients

HRG hemorrhage, ARE adverse radiation effect, BG basal ganglia

The Role of Radiosurgery

The successful management of cerebral AVMs with stereotactic radiosurgery prompted the exploration of its role in the management of cavernous malformations. The benefits of radiosurgery for cavernous malformations are difficult to assess because of its unclear natural history and the lack of an imaging technique that can document a “cure.” The role of radiosurgery in this disease is still considered controversial by many physicians. However, the lack of options for surgically inaccessible cavernous malformations has made radiosurgery a possible alternative to conservative management for lesions with a high risk of symptomatic bleeding (Table 50.3) [17, 34–40].

Table 50.3

Summary of some recent Gamma Knife radiosurgical series of cavernous malformations

First author	Patients/FU	Location	Presentation	Dose/volume	Outcome	Morbidity
Karlsson [34] (1998)	22 patients	Cortical: 8	HRG: 16 patients	Margin: 18 Gy (9–35)	Post-GK HRG rate: 8 %/year	ARE: 6 patients
Karlsson [34] (1998)	22 patients	Deep cerebral: 7	Epilepsy: 6 patients		– Years 1–2: 10 %	– 5 symptoms
GK	6.9 years	Brainstem: 6	Prior resection: 1 patient		– Years 3–4: 12 %	Onset 16 months
		Cerebellum: 1			– Years 5–6: 5 %
					– Years 7–8: 7 %
Hasegawa [17] (2002)	82 patients	Supratentorial: 16	HRG: 82 patients (1–7 bleeds)	Margin: 16.2 Gy (12–20)	HRG: 12.3 % first 2 years	ARE: 11 patients
Hasegawa [17] (2002)	82 patients	Deep: 13	HRG rate: 33.9 %/year		HRG: 0.76 % years 2–12	None after 1992
GK	4.89 years	Brainstem: 52	Prior surgery: 20 patients	Vol.: 1.85 cm³ (0.12–6.98)
Liu [35] (2005)	125 patients	Brainstem: 49	HRG: 112 patients	Margin: 12.1 Gy (9–20)	HRG rate: 6.5 %/year	ARE: 13.1 %
Liu [35] (2005)	125 patients	BG/thalamus: 14	HRG >1: 45 patients		HRG: 10.3 % first 2 years	Symptoms: 2.5 %
GK	5.4 years	Cortical: 39	HRG rate: 29.2 %/year	Vol.: 3.12 cm³ (.032–25.9)	HRG: 3.3 % after year 2
GK	5.4 years	Cerebellum: 10	Seizures: 28 patients
Kim [36] (2005)	42 patients	Cortical: 21	HRG: 26.6 %	Margin: 14.55 Gy (10–25)	Seizure cessation: 75 %	Edema: 5 patients
Kim [36] (2005)	42 patients	Brainstem: 6	Seizures: 28.6 %		– Mean of 31.3 months	– Symptoms: 5 patients
GK	29.6 months	Basal ganglia: 5	Neurological deficit: 45.2 %		HRG: 1	– Recovered: 5 patients
Liscak [37] (2005)	112 patients	Brainstem: 33	HRG in 59 patients	Margin: 16 Gy (9–36)	HRG rate: 1.6 %/year	Edema: 30 patients
Liscak [37] (2005)	112 patients	Cortical: 54	Seizures in 40 patients	Vol.: 0.9 cm³ (0.06–12.5)	– 2 deaths from HRG	– Symptoms: 17 patients
GK	48 months	BG/thalamus: 17	Neurological deficit: 51 patients		Neurological deficits: 33 % improved	– Recovered: 16 patients
GK	48 months	Cerebellum: 8	7 patients prior partial resection
Nagy [38] (2010)	113 patients	Brainstem: 79	HRG high risk >1: 41 patients	Margin: 12–15 Gy (10–20)	High risk <2 years: 15 %/year	ARE: 6 symptoms
Nagy [38] (2010)	113 patients	BG/thalamus: 39	HRG low risk <1: 54 patients	Vol.: 0.33–0.83 cm³	High risk >2 years: 2.4 %/year
GK	48 months		Neurological deficit high risk: 72 %		Low risk <2 years: 5.1 %/year
			Neurological deficit low risk: 43 %		Low risk >2 years: 1.3 %/year
			HRG pre GK: 30.5 %/year
Lunsford [39] (2010)	103 patients	Brainstem: 66	HRG >1: 103 patients	Margin: 16 Gy (12–20)	HRG <2 years: 10.8 %/year	ARE: 19 patients
Lunsford [39] (2010)	103 patients	BG/thalamus: 27	HRG pre GK: 32.5 %/year	Vol.: 1.31 cm³	HRG > 2 years: 1 %/year	Symptoms: 12 patients
GK	67.8 months	Deep lobar: 10	Seizures: 8 patients		75 % seizure cessation
Lee [40] (2012)	49 patients	Pons: 34	HRG >1: 49 patients Only gold members can continue reading. Log In or Register to continue Share this: Click to share on Twitter (Opens in new window) Click to share on Facebook (Opens in new window) Related posts: Imaging Techniques in Stereotactic Radiosurgery Trigeminal Neuralgia: Viewpoint—Medical Management Meningioma—Viewpoint: Fractionated Radiotherapy Skull Base Tumors Arteriovenous Malformations: Viewpoint—Surgery Arteriovenous Malformation Radiosurgery Stay updated, free articles. Join our Telegram channel Tags: Principles and Practice of Stereotactic Radiosurgery Jun 2, 2017 \| Posted by admin in GENERAL RADIOLOGY \| Comments Off on Radiosurgery for Cavernous Malformations and Other Vascular Diseases Full access? Get Clinical Tree Get Clinical Tree app for offline access Get Clinical Tree app for offline access